Oesophagogastric Cancer Surgery Research Articles

Understanding Potentially Preventable Mortality Following Oesophago-Gastric Cancer Surgery: Analysis of a National Audit of Surgical Mortality

IntroductionAt a national level, understanding preventable mortality after oesophago-gastric cancer surgery can direct quality-improvement efforts. Accordingly, utilizing the Australian and New Zealand Audit of Surgical Mortality (ANZASM), we aimed to: (1) determine the causes of death following oesophago-gastric cancer resections in Australia, (2) quantify the proportion of potentially preventable deaths, and (3) identify clinical management issues contributing to preventable mortality.MethodsAll in-hospital mortalities following oesophago-gastric cancer surgery from 1 January 2010 to 31 December 2020 were analysed using ANZASM data. Potentially preventable and non-preventable cases were compared. Thematic analysis with a data-driven approach was used to classify clinical management issues.ResultsOverall, 636 complications and 123 clinical management issues were identified in 105 mortalities. The most common causes of death were cardio-respiratory in aetiology. Forty-nine (46.7%) deaths were potentially preventable. These cases were characterized by higher rates of sepsis (59.2% vs 33.9%, p = 0.011), multiorgan dysfunction syndrome (40.8% vs 25.0%, p = 0.042), re-operation (63.3% vs 41.1%, p = 0.031) and other complications compared with non-preventable mortality. Potentially preventable mortalities also had more clinical management issues per patient [median (IQR): 2 (1–3) vs 0 (0–1), p < 0.001), which adversely impacted preoperative (30.6% vs 7.1%, p = 0.002), intraoperative (18.4% vs 5.4%, p = 0.037) and postoperative (51.0% vs 17.9%, p < 0.001) care. Thematic analysis highlighted recurrent areas of deficiency with preoperative, intraoperative and postoperative patient management.ConclusionsAlmost 50% of deaths following oesophago-gastric cancer resections were potentially preventable. These were characterized by higher complication rates and clinical management issues. We highlight recurrent themes in patient management to improve future quality of care.

OGC P25 Outcomes of Laparoscopic Vs Open Oesophagectomy in a single high volume centre

Abstract Background Oesophageal cancer has a poor 5 year survival and surgery is the mainstay of curative treatment for the majority of cases. Minimally invasive surgery is practiced in a number of formats (open thorax/open abdomen, open thorax/lap abdomen, thoracoscopic/lap abdomen) and its benefits have been subject to a number of trials. Methods We interrogated a prospectively recorded database of oesophagogastric cancer surgery from a large single centre to compare oesophagectomy cases performed with curative intent comparing laparoscopic abdomen plus open thorax versus a totally open operation. Transhiatal oesophagectomies were excluded. Baseline data was compared to establish whether groups were equally matched and outcomes of length of stay, any complication, anastomotic leak, number of lymph nodes yielded, 30 day mortality and 90 day mortality were subject to statistical analysis. Missing data was not imputed. Results Sixty-nine hybrid oesophagectomies (laparoscopic abdomen, open thoracic phase) and 373 totally open procedures were performed between January 2017-May 2022. Both groups were equally matched in terms of age, performance status, ASA, tumour site, gender ratio and histology. LOS was 11.6 vs 13.5 (lap vs open / days), P=0.72. Complication rate was 33.3% v 37.3% (lap vs open) P= 0.53. Anastomotic leak rate was 10.1% vs 8.9% (lap vs open) P=0.73. Number of lymph nodes yielded was 25.8 ± 2.17 vs 24 ± 0.59 (lap vs open, mean ± s.e). Thirty day mortality was 2.9% vs 2.17% (lap vs open) P=0.66. Ninety day mortality was 7.25% vs 4.19% (lap vs open) P=0.27. Conclusions This 5 year dataset of equally matched laparoscopic abdominal phase vs totally open oesophagectomy procedures shows no statistically significant difference in the outcomes that were measured. The laparoscopic approach would be expected to inflict a lesser stress response than open surgery. Oesophagectomy along with possible complications may inflict a stress response that masks the benefits from laparoscopic surgery. This data supports the notion that the laparoscopic abdomen approach is not inferior to an open procedure. Interrogation of a larger 10 year dataset would be worthwhile to confirm this. Furthermore, this current study may be merely be reflective of the learning curve for the laparoscopic approach and a prospective study of our practice will be worthwhile.

OGC P36 Unmet needs in survivorship: Increased anxiety post oesophago-gastric cancer surgery

Abstract Background Oesophago-Gastric (OG) cancer is an aggressive malignant disease, and patients are offered extensive surgical treatment often in combination with neoadjuvant and adjuvant oncological intervention. The treatment process is emotionally demanding and affects treatment outcomes (Fangand, &amp; Schnoll, 2002). However, the available research is concentrated on generalised anxiety and depression (Hellstadius et al, 2017), despite the unique concerns of this cohort. This study examines the trajectory of patients’ unique OG symptoms related anxiety through utilising a specialist measure. Methods The Oesophageal Anxiety and Hypervigilence Scale (EHAS) is a newly validated self-report questionnaire that detects oesophageal anxiety in patience with GI disorders. It has been shown to demonstrate good internal consistency and validity (Taft et al, 2018). Patients with oesophageal cancer were recruited from at Guy's and St Thomas’ Hospital, London. As part of their routine clinic appointments between September 2021-February 2022, patients completed the EHAS measure across four key time points within their treatment trajectory; diagnosis (Time 1), pre-operatively (Time 2), two weeks post operatively (Time 3), and 6–12 months post operatively, often termed ‘survivorship’ (Time 4). Results A total of 106 EHAS measures were completed by 83 patients (79% male, 20% female, mean age = 64) at different stages within their treatment trajectory, representing a between-subjects design. 61% of patients underwent oesophagectomy, 22% total gastrectomy, 10% subtotal gastrectomy and 7% underwent other surgeries including sigmoid colectomy, and jejunal resection. Pooling the sample z-score, the cut off score for clinical significance was calculated at 33. The EHAS outcomes revealed high anxiety at Time 1 (T1 mean = 28/33) which decreased by 32% from to Time 2 (T2 mean = 19/33). Anxiety remained low in the period between Time 2 to Time 3 (T3 mean = 21/33). Surprisingly, anxiety scores increased by 42% from Time 3 to Time 4 (T4 mean = 29/33), matching the elevated levels observed at Time 1. Other important findings related to the proportion of patients that scored above clinical cut off. Whilst 12% of patients scored above cut off at Time 1, this rose to 32% at Time 4, indicating marked anxiety during the phase of recovery greater than that experienced at diagnosis. At this level of analysis there is no evidence to indicate a relationship between type of surgery and elevated anxiety. Conclusions With the use of a specialist anxiety measure, we demonstrate that oesophageal anxiety is common among OG cancer patient cohort. The trajectory of anxiety observed in this study has clinical implications for the timing of support and enhanced recovery programme; this study revealed that OG anxiety fluctuated across the treatment pathway, and peaked at two distinct time points; diagnosis and survivorship. This challenges the often held assumption that patients anxiety increases pre-operatively (Hellstadius et al, 2017), and instead refocuses the need for input at both the diagnosis and survivorship periods. The high anxiety observed at the survivorship stage may also affect patients’ ability to process and adhere to treatment advice, further exacerbating their symptoms and jeopardising their physical recovery. Patients are monitored less during their survivorship period as the intensity of treatment cease, however the results indicate need for continued input.

OGC P27 A Review of Minimally Invasive Oesophagogastric Cancer Surgery in a High-Volume UK Unit

Abstract Background Oesophagogastric (OG) cancer resections are technically challenging and associated with peri-operative morbidity. Practice has evolved from open to minimally invasive surgery (MIS), with ERAS has seen peri-operative outcomes improve. OG surgeons have not transitioned to MIS at the rate of others; 2021 NOGCA results showed that 17.6% of oesophagectomies and 17% of gastrectomies were performed as MIS. Concerns regarding the technical ability to perform safe anastomoses and appropriate oncological clearance have been cited as common reasons for surgeons not transitioning to MIS. GSTT is a high-volume OG unit which has transitioned from a fully open to predominantly MIS practice. The unit has performed over 100 minimally invasive Ivor Lewis oesophagectomies and 97 laparoscopic gastrectomies, it was therefore decided to analyse the unit's peri-operative outcomes to ensure that appropriate standards were maintained during this change in practice. The primary aim of this study was to examine a decade of peri-operative outcomes for Ivor Lewis oesophagectomy and gastrectomies, comparing parallel open and MIS cohorts. The secondary aim is to perform a sequential cumulative sum control chart (CUSM) analysis of the cohort to determine whether a learning curve effect for OG MIS can be demonstrated. Methods A retrospective analysis of a prospectively maintained comprehensive local database was performed. The results were cross-checked with NOCGA data, and a notes review was performed to capture any missing data.All Ivor Lewis oesophagectomy and gastrectomy (total, extended total and subtotal) performed for adenocarcinoma, squamous cell carcinoma, neuroendocrine tumours and high grade dysplasia at Guy's and St Thomas’ NHS Foundation Trust, London, UK over a ten-year period (January 2012- December 2021) were included. MIS for oesophagectomy was defined as an Ivor Lewis oesophagectomy performed with both laparoscopic and thoracoscopic phases. A hybrid (laparoscopic abdomen and open chest phase) oesophagectomy was grouped with a two-phase open procedure to create an open cohort. Laparoscopic gastrectomy (with a laparoscopic oesophago-jejunostomy or gastro-jejunostomy for sub-total gastrectomy) was used as the definition of MIS. The cohorts were compared for: age, sex, BMI and use of neoadjuvant therapy. Temporal trends in surgical approaches were compared as were Individual surgeon (n=4) volumes. Peri-operative clinical and oncological outcomes including length of stay, anastomotic leak, return to theatre, chest complications, resection margins and lymph node harvest were all examined. A CUSM analysis is currently being completed to further analyse surgeon performance over time. Results 596 patients underwent resection in well matched cohorts, 197 patients had an oesophagectomy (100 MIO), 339 had a gastrectomy (97 laparoscopic). MIS rates increased with no operations being performed as MIS in 2012 compared to 81% of oesophagectomy and 67% of gastrectomy performed as MIS in 2021. Two surgeons performed over 170 resections with MIS rate over 40%. OR of MIS performed by a high-volume surgeon was 3.01 (p&amp;lt;0.001). Lower volume MIS surgeons were more likely to have two consultants present, OR 1.4 (p=0.16). Anastomotic leak rates following gastrectomy were 2% in both groups (p=0.66), 9% following open oesophagectomy and 11% after MIO (p=0.77). 10% of laparoscopic gastrectomy patients experienced a chest complication, 26% after open surgery, 22% MIO and 24% open (p=0.65). Mean length of stay was significantly reduced after MIS. An R0 rate of 96% was seen after laparoscopic gastrectomy, 90% after open (p=0.08). 68% of MIO patients had R0 resection compared to 70% after open. Positive CRM was 29% after MIO. The mean lymph node harvest was 29 after laparoscopic gastrectomy and 26 after open (p=0.24), 29 following MIO, 30 after open oesophagectomy. 97% of MIO harvested over 15 nodes. Conclusions This study demonstrates that a transition from open to MIS practice is achievable in the UK. Outcomes demonstrated similar peri-operative clinical and oncological outcomes between MIS and open surgery which addresses the concerns that prohibited the widespread uptake of MIS in UK centres. Developing a reliable surgical technique for lymphadenectomy and anastomoses that transitioned from open to hybrid and now MIS allowed for appropriate outcomes to be maintained. Unit outcomes compare well to both NOGCA/ECCG data with complication rates following MIO being significantly lower when compared to ECCG. Lymph node harvests were significantly higher in unit MIOs when compared to NOGCA (p=0.01). Volume played an important role in surgeons performing independent MIS. This should be considered when planning unit workload or a transition to MIS. It will be further explored in the CUSM analysis. A positive CRM was seen in more cases (29%) when compared to NOGCA (24%) and may be related to the preferred neoadjuvant regime being chemotherapy over chemoradiotherapy. The future of OG is moving towards robotic surgery. It is proposed that the evolution from open to MIS will make a second transition to robotics less challenging as the strategies needed to perform MIS have been addressed.

261. MALNUTRITION DEFINED BY GLIM CRITERIA ASSOCIATES WITH INCREASED RISK OF ADVERSE OUTCOME AFTER OESOPHAGO-GASTRIC CANCER SURGERY

Abstract Low muscle mass is associated with postoperative complications after oesophago-gastric (OG) cancer surgery, but data demonstrating a negative impact on long-term survival is limited. Clinical tools to accurately stratify risk based on nutritional status would be of considerable value. The Global Leadership Initiative on Malnutrition (GLIM) is a consensus framework for diagnosing malnutrition. We aimed to assess the prevalence of malnutrition defined by GLIM and the impact on postoperative outcomes after OG cancer surgery. Patients who underwent radical OG cancer surgery with preoperative abdominal computed tomography (CT) imaging were included. Retrospective collection of preoperative data identified malnutrition using the GLIM definition. The phenotypic criterion includes body mass index (BMI), unintentional weight loss, and muscle mass. All patients had a malignant disease and met the aetiologic criterion of an inflammatory condition. Nutrition status was categorised as no malnutrition, mild–moderate, and severe. Malnutrition diagnosis was assessed against oncological, surgical, and survival data. Low skeletal muscle index (cm2/m2) measured by CT was determined using predefined cut-points.1 Cox regression analysis determined predictors of overall survival. One-hundred and eight patients were included. Malnutrition using GLIM criteria was present in 72% of patients (n = 78), including mild–moderate (n = 45) and severe malnutrition (n = 33). The predominant phenotypic criterion for GLIM malnutrition was low muscle mass (n = 66, 61%), followed by preoperative weight loss (n = 46, 43%) and low BMI (n = 11, 10%). Malnutrition was associated with postoperative pneumonia (26.9% vs 6.7% well-nourished, p = 0.010). Severe malnutrition was associated with poorer 5-year overall survival (p = 0.022) (Figure 1) and, along with stage 4 disease, higher age, and severe postoperative complications, remained an independent predictor of survival after multivariate analysis (OR 2.51, 95% CI 1.20–5.24, p = 0.014). Malnutrition defined by GLIM is highly prevalent and is associated with postoperative pneumonia. Severe malnutrition is an independent predictor of poorer overall survival. Muscle mass is a key phenotypic GLIM criterion, and the GLIM diagnostic framework is potentially a practical and valuable component of preoperative risk stratification in OG cancer surgery.

A feasibility trial of prehabilitation before oesophagogastric cancer surgery using a multi-component home-based exercise programme: the ChemoFit study

BackgroundTreatment for locally advanced oesophagogastric adenocarcinoma involves neoadjuvant chemotherapy which has a negative impact on patient fitness. Using ‘prehabilitation’ to increase activity levels and fitness may affect physiology, postoperative outcomes and improve patient wellbeing and quality of life. The aims of the trial were to address the feasibility and acceptability of recruiting participants to a home-based prehabilitation programme and provide data to allow design of future studies.MethodsWe recruited patients to a single-arm feasibility trial of home-based exercise prehabilitation. Eligible patients were aged ≥18years, had operable oesophageal or gastric adenocarcinoma and were receiving neoadjuvant chemotherapy at our tertiary referral hospital. All participants commenced a home-based exercise programme utilising pedometers and step counting to target daily aerobic exercise sessions alongside daily strengthening exercises. A weekly telephone consultation directed the exercise programme and facilitated weekly data collection. The primary (feasibility) outcomes for the trial were (a) recruitment rate, (b) completion rate, (c) engagement with the programme (use of pedometers, recording step counts, telephone consultations) and (d) compliance with exercise sessions, exercise intensity and strengthening exercises.ResultsThere were 42 patients recruited, and the recruitment rate was 72.4% (42/58). 92.3% (36/39) of patients completed the exercise programme. There was 98.7% (IQR 93.2–100.0%) compliance with wearing a pedometer and recording data, and 100.0% (IQR 93.1–100.0%) compliance with a weekly telephone consultation. Exercise sessions and strengthening exercises were completed 70.2% (IQR 53.1–88.9%) and 69.4% (IQR 52.1–84.3%) of the time, respectively. Appropriate exercise intensity was recorded 96% (IQR 85.4–99.4%) of the time. There were no adverse events. Participants were enrolled in the exercise programme for a median of 91 days (IQR 84 to 105 days).ConclusionsThe results of this trial support the feasibility and acceptability of recruiting participants to an appropriately powered randomised controlled trial of prehabilitation.Trial registrationClinicaltrials.gov NCT04194463. Registered on 11th December 2019—retrospectively registered.

19: CARDIOPULMONARY FUNCTION FOLLOWING NEO-ADJUVANT CHEMOTHERAPY FOR OESOPHAGO-GASTRIC ADENOCARCINOMA

Abstract Background and aim The role of perioperative chemotherapy in oesophago-gastric adenocarcinoma is well established. Epirubicin, Cisplatin/Oxaliplatin and Capecitabine (ECX/EOX) based regimens have recently been challenged by Fluoruracil, Leucovorin, Oxaliplatin and Docetaxel (FLOT). We aimed to assess whether these regimens had variable effects on patient cardiopulmonary fitness and subsequent suitability for major surgery following treatment. Methods Cardiopulmonary exercise (CPEX) testing was used to provide objective estimation of cardiopulmonary function metrics including peak oxygen consumption (VO₂ max), anaerobic threshold (AT) and ventilatory efficiency (VeVCO₂ slope). Paired CPEX testing was performed in participants undergoing treatment for oesophago-gastric adenocarcinoma pre and post FLOT (n = 26) or ECX/EOX (n = 51) chemotherapy regimens, as selected by the multidisciplinary team. Univariate non-parametric testing was used to assess differences for significance. Results Participants undergoing FLOT were younger [median (IQR): 61(12.5) □□. 69(11) years, P = 0.003] and had a higher pre-chemotherapy VO₂ max/m2 [929(231) □□. 838(198) ml/m2/min, P = 0.040] and FEV1 [3.5(0.8) □□. 2.9(0.6), P = 0.017] compared to those undergoing ECX/EOX. Other metrics including BMI, weight, VO₂ max/kg, AT, VeVCO₂ slope, FVC and FEV1 were not significantly different at baseline. There was no difference in time to CPEX testing after completing chemotherapy treatment [median 27 □□. 27 days]. Both FLOT and ECX/EOX significantly reduced VO₂ max/kg [−2.85(4.0) &amp; -1.70(3.5) ml/kg/min], VO₂ max/m2 [−101(193) &amp; -68(155) ml/m2/min] and AT [−1.35(2.7) &amp; -1.1(2.3) ml/kg/min] respectively (all P &amp;lt; 0.001), with no significant absolute or proportional differences found between the groups. Respiratory function was not altered. Conclusion A reduction in cardiopulmonary function should be accounted for when planning surgery for oesophago-gastric cancer following neo-adjuvant chemotherapy. We did not find significant differences in cardiopulmonary function reduction between chemotherapy regimens in this cohort. However, there was a trend towards a greater reduction in cardiopulmonary function after FLOT and studies in larger cohorts of patients are needed to clarify this.

Micronutrient deficiencies following surgery for oesophagogastric cancer – is there a need for introduction of a novel nutritional pathway?

Micronutrients are essential for optimal health. Deficiencies may result in reduced psychological wellbeing, increased fatigue, reduced performance status and consequently impaired quality of life. Management of micronutrients is an area often overlooked in standard pathways for patients who have undergone surgery for oesophagogastric cancer. Improved outcomes and survivorship following radical treatment for these patients mean we can no longer overlook micronutrient deficiency which may have a detrimental effect on patients quality of life and wellbeing following surgery (I).

"Attending to History" in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration.

The reconfiguration of specialist hospital services, with service provision concentrated in a reduced number of sites, is one example of major system change (MSC) for which there is evidence of improved patient outcomes. This paper explores the reconfiguration of specialist oesophago-gastric (OG) cancer surgery services in a large urban area of England (Greater Manchester, GM), with a focus on the role of history in this change process and how reconfiguration was achieved after previous failed attempts. This study draws on qualitative research from a mixed-methods evaluation of the reconfiguration of specialist cancer surgery services in GM. Forty-six interviews with relevant stakeholders were carried out, along with ~160 hours of observations at meetings and the acquisition of ~300 pertinent documents. Thematic analysis using deductive and inductive approaches was undertaken, guided by a framework of 'simple rules' for MSC. Through an awareness of, and attention to, history, leaders developed a change process which took into account previous unsuccessful reconfiguration attempts, enabling them to reduce the impact of potentially challenging issues. Interviewees described attending to issues involving competition between provider sites, change leadership, engagement with stakeholders, and the need for a process of change resilient to challenge. Recognition of, and response to, history, using a range of perspectives, enabled this reconfiguration. Particularly important was the way in which history influenced and informed other aspects of the change process and the influence of stakeholder power. This study provides further learning about MSC and the need for a range of perspectives to enable understanding. It shows how learning from history can be used to enable successful change.

P-OGC71 Five positive lymph nodes are a significant negative indicator of survival in Oesophago-Gastric Cancer surgery: an 8-year study

Abstract Background Number of positive lymph nodes involved is an important prognostic indicator in Oesophago-Gastric cancer survival post surgery. We present an 8 year study examining the number of lymph nodes involved and its impacts on long term cancer survival and in particular to determine whether there is a threshold after which survival is significantly worsened. Methods A prospectively maintained single-institution database containing data from all patients from Jan 2012 to Dec 2020 was analysed. Survival analyses were undertaken to determine the association between lymph node positivity and survival. Results A total of 430 patients underwent surgery for gastro-oesophageal cancer (oesophagectomy: n = 311, 72.3%; gastrectomy n = 119, 27.7%) of which 80.2% were male and the median age was 68 years old (IQR: 61-74). A median of 23 nodes were examined (IQR 18-33) and a median of one lymph node was positive for cancer (IQR 0-3 lymph nodes). The majority of patients (59.3%) had a T3 tumour, 24.0% had T2, and 12.1% had a T1 tumour. Over a median follow up of 30 months (IQR 13-61), 61.2% of the study population were alive. Kaplan Meier analyses demonstrated that patients who had five or more positive nodes had a survival of 36.3 months (IQR: 24.4-48.3 months) compared to those with four or fewer nodes (45.8 months, IQR: 27.6-64.1 months, p &amp;gt; 0.001). Survival did not worsen further with a higher number of positive nodes. Conclusions This study shows that having five or more positive lymph nodes significantly worsens Oesophago-gastric cancer survival. These results may suggest that from the threshold of 5 positive nodes, OG cancer behaves as a systemic disease and thus impact on adjuvant treatment strategies.

P-OGC53 Dashboarding for real-time analysis of oesophagogastric outcomes data

Abstract Background The typical paradigm for surgical service evaluation is intermittent audit based on perceived clinical need and mandated requirements. A better model would be monitoring patient outcomes automatically in real-time, with up-to-date cumulative frequencies of key surgical performance indicators such as surgical quality and morbidity, as changes in performance could be detected and reacted to at an earlier stage. This study aimed to develop a dashboarding technology to support real-time visualisation of prospectively maintained oesophagogastric cancer surgery data. Methods CODA is a bespoke databank (implemented in MS SQL Server, with HTML, C# and JavaScript) for oesophagogastric cancer care at our centre. We built on a custom dashboard interface for displaying this information in real-time, using Shiny for R and Tableau. We identified the key performance indicators (KPIs) to monitor in the dashboard, and defined benchmarks based on accepted standards, or our prevailing performance (based on 448 consecutive patients who underwent oesophagectomy between 2015 – 2020). The domains selected were surgical quality, length of stay, early mortality, and priority complications. Complications were defined according to the Esophagectomy Complications Consensus Group. Results For surgical quality, our benchmarks based on prevailing performance were (i) &amp;gt;90% &amp;gt;15 lymph node yield (ii) &amp;lt;2-5% longitudinal R1 (iii) &amp;lt;20-30% CRM R1. For length of stay, our benchmarks were (i) &amp;gt;33% meeting 8 day discharge target (ii) &amp;lt;15% missing target discharge without a medical complication (iii) &amp;lt;20% staying longer than two weeks. For 30 &amp; 90 day mortality, our benchmarks were 2% and 4% respectively. For complications, two sets were identified: (i) common complications (occurring at &amp;gt; 2 / year, monitored 2-yearly) (ii) impactful complications (&amp;gt;1 / year, &amp;gt;1 week median additional stay, monitored 5-yearly) Conclusions The CODA dashboard provides real-time appraisal of oesophagogastric cancer surgery practice, highlighting changes in performance and providing opportunity for early intervention. The platform can be used for personal, departmental or inter-institutional service evaluation. The KPIs will be extended to oesophagogastric cancer survival as the test set matures. The interface and wider benefits of CODA implementation are presented, together with the dissemination plan for use in other oesophagogastric centres.

P-OGC76 A patient engagement event to assess feasibility of preoperative enhanced recovery groups in patients with oesophagogastric cancer undergoing surgery

Abstract Background Enhanced recovery (ER) includes pre-operative counselling during individual patient consultations with multidisciplinary team (MDT) members. Patients can experience lengthy appointments seeing multiple professionals. This negatively impacts on their ability to retain and process information, and results in long, overrunning clinics. Separate, virtual ER group sessions have been proposed to deliver aspects of the pre-operative appointment which are common to all patients undergoing oesophagogastric (OG) cancer surgery. The aim is to improve patient engagement and experience, and improve efficiency of clinics. A patient engagement event was undertaken to gain feedback from patients about the existing service and the proposed virtual group. Methods A semi-structured telephone interview was developed with the support of a Patient &amp; Public Engagement Team. The 30 minute interview covered aspects such as patient experience of ER information delivery, the quality of the information they received and their thoughts on attending virtual group sessions. Seventy patients, who had undergone surgery for OG cancer in the previous 14 months were invited to take part. A Health Informatics Team screened the patient list prior to invitation letters being sent. The telephone interviews took place in November 2020. Results Twenty-seven patients responded (37%). Of these, 89% felt they received all information required for surgery preparation. Over 50% reported receiving adequate information to support with common post-operative issues (dietary - 81%; physical activity - 55%) but would like more on others (psychological impact - 26%). Patients highlighted that the MDT clinic took many hours and information delivery was overwhelming. The internet was accessible to 85% and 56% thought the information provided prior to surgery could have been delivered in a virtual group. Patient perceived advantages to virtual groups included: peer support; reduced travel; and avoidance of information repetition and overload. Conclusions Patient preference, perspective and needs are paramount when designing healthcare services. Results from this patient engagement event suggest that the delivery of preoperative information and counselling as part of ER could be improved through the implementation of virtual ER groups. They also suggest that most patients perceive benefits to such a model, including the addition of peer support. The next steps in the proof of concept are to develop the virtual groups MDT content and pilot in a cohort of patients, evaluating patient related outcome measures and impact on service efficiency.

Postoperative arginine-enriched immune modulating nutrition: Long-term survival results from a randomised clinical trial in patients with oesophagogastric and pancreaticobiliary cancer

SummaryBackground & aimsImmune modulating nutrition (IMN) has been shown to reduce postoperative infectious complications and length of stay in patients with gastrointestinal cancer. Two studies of IMN in patients undergoing surgery for head and neck cancer also suggested that this treatment might improve long-term survival and progression-free survival. In the present study, we analysed follow-up data from our previous randomised controlled trial of IMN, in patients undergoing surgery for oesophagogastric and pancreaticobiliary cancer, in order to evaluate the long-term impact on survival of postoperative IMN versus an isocaloric, isonitrogenous control feed.MethodsThis study included patients undergoing surgery for cancers of the pancreas, oesophagus and stomach, who had been randomised in a double-blind manner to receive postoperative jejunostomy feeding with IMN (Stresson, Nutricia Ltd.) or an isonitrogenous, isocaloric feed (Nutrison High Protein, Nutricia) for 10–15 days. The primary outcome was long-term overall survival.ResultsThere was complete follow-up for all 108 patients, with 54 patients randomised to each group. There were no statistically significant differences between groups by demographics [(age, p = 0.63), sex (p = 0.49) or site of cancer (p = 0.25)]. 30-day mortality was 11.1% in both groups. Mortality in the intervention group was 13%, 31.5%, 70.4%, 85.2%, 88.9%, and 96.3% at 90 days, and 1, 5, 10, 15 and 20 years respectively. Corresponding mortality in the control group was 14.8%, 35.2%, 68.6%, 79.6%, 85.2% and 98.1% (p > 0.05 for all comparisons).ConclusionEarly postoperative feeding with arginine-enriched IMN had no impact on long-term survival in patients undergoing surgery for oesophagogastric and pancreaticobiliary cancer.

Low muscularity increases the risk for post-operative pneumonia and delays recovery from complications after oesophago-gastric cancer resection.

Low muscularity is associated with adverse surgical outcomes. We aimed to determine whether low muscularity is associated with an increased risk of post-operative complications and reduced long-term survival after oesophago-gastric cancer surgery. Patients who underwent radical oesophago-gastric cancer surgery with preoperative abdominal computed tomography (CT) imaging were included. Low skeletal muscle index (SMI), measured by CT, was determined using pre-defined cut-points. Oncological, surgical, complications and outcome data were obtained from a prospective database. Of 108 patients, 61% (n=66) had low SMI preoperatively. Patients with low SMI had a higher rate of post-operative pneumonia (30 vs. 7% normal muscularity, P=0.004). Median length of stay (LOS) was higher in patients with low SMI if they had any complication (19.5 vs. 14 days, P=0.026) or pneumonia (21 vs. 13 days, P=0.018). On multivariate analysis, low SMI (OR 3.85, CI 1.10-13.4, P=0.025), preoperative weight loss (OR 1.13, CI 1.01-1.25, P=0.027), and smoking (OR 5.08, CI 1.24-20.9, P=0.024) were independent predictors of having a severe complication. There was no difference in 5-year overall (62% vs. 69%, P=0.241) and disease-free (11% vs. 21.4%, P=0.110) survival between low SMI and normal muscle mass groups. Low SMI is associated with a significantly increased risk of pneumonia and increased LOS for patients with complications. Assessment of muscle mass may require additional muscle quality, strength, and physical performance measures to enhance preoperative risk assessment.

Cardiopulmonary exercise testing has greater prognostic value than sarcopenia in oesophago‐gastric cancer patients undergoing neoadjuvant therapy and surgical resection

Sarcopenia (low skeletal muscle mass), myosteatosis (low skeletal muscle radiation-attenuation) and fitness are independently associated with postoperative outcomes in oesophago-gastric cancer. This study aimed to investigate (1) the effect of neoadjuvant therapy (NAT) on sarcopenia, myosteatosis and cardiopulmonary exercise testing (CPET), (2) the relationship between these parameters, and (3) their association with postoperative morbidity and survival. Body composition analysis used single slice computed tomography (CT) images from chest (superior to aortic arch) and abdominal CT scans (third lumbar vertebrae). Oxygen uptake at anaerobic threshold (VO2 at AT) and at peak exercise (VO2 Peak) were measured using CPET. Measurements were performed before and after NAT and an adjusted regression model assessed their association. Of the 184 patients recruited, 100 underwent surgical resection. Following NAT skeletal muscle mass, radiation-attenuation and fitness reduced significantly (p < 0.001). When adjusted for age, sex, and body mass index, only pectoralis muscle mass was associated with VO2 Peak (p = 0.001). VO2 at AT and Peak were associated with 1-year survival, while neither sarcopenia nor myosteatosis were associated with morbidity or survival. Skeletal muscle and CPET variables reduced following NAT and were positively associated with each other. Cardiorespiratory function significantly contributes to short-term survival after oesophago-gastric cancer surgery.

The effects of cancer therapies on physical fitness before oesophagogastric cancer surgery: a prospective, blinded, multi-centre, observational, cohort study.

BackgroundNeoadjuvant cancer treatment is associated with improved survival following major oesophagogastric cancer surgery. The impact of neoadjuvant chemo/chemoradiotherapy on physical fitness and operative outcomes is however unclear. This study aims to investigate the impact of neoadjuvant chemo/chemoradiotherapy on fitness and post-operative mortality.MethodsPatients with oesophagogastric cancer scheduled for chemo/chemoradiotherapy and surgery were recruited to a prospective, blinded, multi-centre, observational cohort study. Primary outcomes were changes in fitness with chemo/chemoradiotherapy, measured using cardiopulmonary exercise testing and its association with mortality one-year after surgery. Patients were followed up for re-admission at 30-days, in-hospital morbidity and quality of life (exploratory outcomes).ResultsIn total, 384 patients were screened, 217 met the inclusion criteria, 160 consented and 159 were included (72% male, mean age 65 years). A total of 132 patients (83%) underwent chemo/chemoradiotherapy, 109 (71%) underwent chemo/chemoradiotherapy and two exercise tests, 100 (63%) completed surgery and follow-up. A significant decline in oxygen uptake at anaerobic threshold and oxygen uptake peak was observed following chemo/chemoradiotherapy: -1.25ml.kg-1.min-1 (-1.80 to - 0.69) and -3.02ml.kg-1.min-1 (-3.85 to -2.20); p<0.0001). Baseline chemo/chemoradiotherapy anaerobic threshold and peak were associated with one-year mortality (HR=0.72, 95%CI 0.59 to 0.88; p=0.001 and HR=0.85, 0.76 to 0.95; p=0.005). The change in physical fitness was not associated with one-year mortality.ConclusionChemo/chemoradiotherapy prior to oesophagogastric cancer surgery reduced physical fitness. Lower baseline fitness was associated with reduced overall survival at one-year. Careful consideration of fitness prior to chemo/chemoradiotherapy and surgery is urgently needed.

Myosteatosis predicts higher complications and reduced overall survival following radical oesophageal and gastric cancer surgery

IntroductionLow muscle attenuation, as governed by increased intramuscular fat infiltration (myosteatosis), may associate with adverse surgical outcomes. We aimed to determine whether myosteatosis is associated with an increased risk of postoperative complications and reduced long-term survival after oesophago-gastric (OG) cancer surgery. MethodsPatients who underwent radical OG cancer surgery with preoperative abdominal computed tomography (CT) imaging were included. Myosteatosis was evaluated using previously defined cut-points for low skeletal muscle attenuation measured by CT. Oncological, surgical, complications, and outcome data were obtained from a prospective database. ResultsOf 108 patients, 56% (n = 61) had myosteatosis. Patients with myosteatosis were older (69.1 ± 9.1 vs. 62.8 ± 9.8 years, p = 0.001) and had a similar body mass index (BMI) (23.4 ± 5.3 vs. 25.9 ± 6.7 kg/m2, p = 0.766) compared to patients with normal muscle attenuation. Patients with myosteatosis had a higher rate of anastomotic leaks (15% vs. 2%, p = 0.041). On multivariate analysis, myosteatosis was an independent predictor of overall (OR 3.03, 95% CI 1.31–6.99, p = 0.009) and severe complications (OR 4.33, 95% CI 1.26–14.9, p = 0.020). Patients with myosteatosis had reduced 5 year overall (54.1% vs. 83%, p = 0.004) and disease-free (55.2% vs. 87.2%, p = 0.007) survival. ConclusionMyosteatosis is associated with a significantly increased risk of overall and severe complications as well as substantially reduced long-term survival. Assessment of muscle attenuation provides analysis beyond standard anthropometrics and may form part of preoperative physiological staging tools used to improve surgical outcomes.

Hospital characteristics associated with better 'quality of surgery' and survival following oesophagogastric cancer surgery in Queensland: a population-level study.

The impact of hospital characteristics on the quality of surgery and survival following oesophagogastric cancer surgery has not been well established in Australia. We assessed the interaction between hospital volume, service capability and surgical outcomes, with the hypothesis that both the quality of surgery and survival are better following treatment in high-volume, high service capability hospitals. All patients undergoing oesophagectomy and gastrectomy for cancer in Queensland, between 2001 and 2015, were included. Demographic, pathology and outcome data were collected. Hospitals were categorized into high (HV) (≥5 gastrectomies; ≥6 oesophagectomies) and low volume (LV). Hospital service capability was defined as high (HS) and low (LS), and then linked to hospital volume: HVHS, LVHS and LVLS. Higher quality surgery was defined using six perioperative parameters. Univariable comparisons of quality of surgery between hospital groups used chi-squared tests. The 5-year overall survival was compared using log-rank tests and Cox proportional hazard models. For both gastrectomy and oesophagectomy, higher quality surgery occurred more frequently in HVHS hospitals (gastrectomy: HVHS = 44.2%, LVHS = 23.1%, LVLS = 29.1% (P < 0.01); oesophagectomy: HVHS = 34.5%, LVHS = 24.4%, LVLS = 21.7% (P = 0.01)). Following oesophagectomy, the 3- and 5-year overall survival was better following treatment in HVHS (P < 0.01). There was no difference between the groups following gastrectomy. In Queensland, the quality of surgery was higher in HVHS hospitals performing gastrectomy and oesophagectomy; however, the impact on cancer survival was only seen following oesophagectomy.

Impact of sex and age on chemotherapy efficacy, toxicity and survival in localised oesophagogastric cancer: A pooled analysis of 3265 individual patient data from four large randomised trials (OE02, OE05, MAGIC and ST03)

BackgroundThere is a lack of large-scale randomised data evaluating the impact of sex and age in patients undergoing chemotherapy followed by potentially curative surgery for oesophagogastric cancer. Patients and methodsIndividual patient data from four prospective randomised controlled trials were pooled using a two-stage meta-analysis. For survival analysis, hazard ratios (HRs) were calculated for patients aged <70 and ≥ 70 years, as well as between males and females. Mandard tumour regression grade (TRG) and, ≥grade III toxicities were compared using logistic regression models to calculate odds ratios. All analyses were adjusted for the type of chemotherapy received. Results3265 patients were included for survival analysis (2668 [82%] male, 597 [18%] female; 2627 (80%) <70 years, 638 (20%) ≥70 years). A significant improvement in overall survival (OS) (HR: 0.78; p < 0.001) and disease-specific survival (DSS) (HR: 0.78; p < 0.001) was observed in females compared with males. No significant differences in OS (HR: 1.11; p = 0.045) or DSS (HR: 1.01; p = 0.821) were observed in older patients compared with younger patients.For patients who underwent resection, older patients (15% vs 10%; p = 0.03) and female patients (14% vs 10%, p = 0.10) were more likely to achieve favourable Mandard TRG scores. Females experienced significantly more ≥grade III nausea (10% vs 5%; p≤0.001), vomiting (10% vs 4%; p≤0.001) and diarrhoea (9% vs 4%; p≤0.001) than males. ConclusionsIn this large pooled analysis using prospective randomised trial data, females had significantly improved survival while experiencing more gastrointestinal toxicities. Older patients achieved comparable survival to younger patients and thus, dependent on fitness, should be offered the same treatment paradigm.

Value of individual surgeon performance metrics as quality assurance measures in oesophagogastric cancer surgery.

BackgroundSurgeon‐level operative mortality is widely seen as a measure of quality after gastric and oesophageal resection. This study aimed to evaluate this alongside a compound‐level outcome analysis.MethodsConsecutive patients who underwent treatment including surgery delivered by a multidisciplinary team, which included seven specialist surgeons, were studied. The primary outcome was death within 30 days of surgery; secondary outcomes were anastomotic leak, Clavien–Dindo morbidity score, lymph node harvest, circumferential resection margin (CRM) status, disease‐free (DFS), and overall (OS) survival.ResultsThe median number of annual resections per surgeon was 10 (range 5–25), compared with 14 (5–25) for joint consultant teams (P = 0·855). The median annual surgeon‐level mortality rate was 0 (0–9) per cent versus an overall network annual operative mortality rate of 1·8 (0–3·7) per cent. Joint consultant team procedures were associated with fewer operative deaths (0·5 per cent versus 3·4 per cent at surgeon level; P = 0·027). The median surgeon anastomotic leak rate was 12·4 (range 9–20) per cent (P = 0·625 versus the whole surgical range), overall morbidity 46·5 (31–60) per cent (P = 0·066), lymph node harvest 16 (9–29) (P < 0·001), CRM positivity 32·0 (16–46) per cent (P = 0·003), 5‐year DFS rate 44·8 (29–60) per cent and OS rate 46·5 (35–53) per cent. No designated metrics were independently associated with DFS or OS in multivariable analysis.ConclusionAnnual surgeon‐level metrics demonstrated wide variations (fivefold), but these performance metrics were not associated with survival.